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A Dissertation on

A COMPARATIVE CROSS-SECTIONAL STUDY ON SELF- CARE PRACTICES AMONG PATIENTS WITH TYPE 2 DIABETES MELLITUS IN RURAL AND URBAN AREAS

IN SALEM DISTRICT, TAMILNADU

Submitted to

THE TAMILNADU DR. M.G.R. MEDICAL UNIVERSITY CHENNAI – 600032

In partial fulfilment of the regulations For the award of the Degree of

M.D. BRANCH – XV COMMUNITY MEDICINE

Reg No: 201725353

THE TAMIL NADU DR. M.G.R MEDICAL UNIVERSITY CHENNAI, TAMIL NADU.

MAY – 2020

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CERTIFICATE

This is to certify that dissertation titled “A COMPARATIVE

CROSS-SECTIONAL STUDY ON SELF-CARE PRACTICES

AMONG PATIENTS WITH TYPE 2 DIABETES MELLITUS IN RURAL AND URBAN AREAS IN SALEM DISTRICT,

TAMILNADU” is a bonafide work carried out by Dr P.V.SHARMILA,

Post Graduate Student in the Department of Community Medicine, Government Stanley Medical College, Chennai- 600 001,under the guidance of Dr. P. SEENIVASAN, M.D, towards partial fulfilment of the requirements for the degree of M.D. Branch XV Community Medicine and is being submitted to the Tamil Nadu Dr.M.G.R Medical University, Chennai

DR.R. SHANTHIMALAR M.D., D.A., DR.P. SEENIVASAN M.D.

Dean, Professor and Head

Govt.Stanley Medical College Department of Community Medicine

& Hospital, Chennai – 01. Govt.Stanley Medical College,

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CERTIFICATE BY THE GUIDE

This is to certify that dissertation titled

“A COMPARATIVE CROSS-SECTIONAL STUDY ON SELF-CARE PRACTICES AMONG PATIENTS WITH TYPE 2 DIABETES MELLITUS IN RURAL AND URBAN AREAS IN SALEM DISTRICT, TAMILNADU” is a bonafide work carried out by Dr.P.V.SHARMILA,Post Graduate Student in the Department of

Community Medicine, Government Stanley Medical College, Chennai- 600 001,under my guidance and supervision towards partial fulfilment of the requirements for the degree of M.D. Branch XV Community Medicine and is being submitted to the Tamil Nadu Dr.M.G.R Medical

University, Chennai.

Signature of the guide

Place: Chennai Dr. P.SEENIVASAN M.D.,

Date:

11.02.2020

Professor and Head,

Department of Community Medicine, Govt.StanleyMedical College, Chennai – 600001.

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CERTIFICATE-II

This is to certify that this dissertation work “A COMPARATIVE

CROSS-SECTIONAL STUDY ON SELF-CARE PRACTICES

AMONG PATIENTS WITH TYPE 2 DIABETES MELLITUS IN RURALAND URBAN AREAS IN SALEM DISTRICT, TAMILNADU” of the candidate Dr P.V. SHARMILA with registration

number 201725353 for the award of M.D. COMMUNITY MEDICINE in the branch of XV. I personally verified the urkund.com website for the purpose of plagiarism check. I found that the uploaded thesis file contains from introduction to conclusion pages and result shows 7 percentage of plagiarism in the dissertation.

Place: Chennai Guide & Supervisor sign with Seal

Date: 11.02.2020

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DECLARATION

I, solemnly declare that the dissertation titled “A COMPARATIVE

CROSS-SECTIONAL STUDY ON SELF-CARE

PRACTICES AMONG PATIENTS WITH TYPE 2 DIABETES MELLITUS IN RURALAND URBAN AREAS IN SALEM

DISTRICT,TAMILNADU”

was done by me under the guidance and supervision of

Dr.P.SEENIVASAN M.D.,

Professor and Head Department of Community Medicine, Government Stanley Medical College,Chennai-01. The dissertation is submitted to The Tamilnadu Dr.M.G.R. Medical University, Chennai towards partial fulfilment of the requirement for the award of M.D. degree (Branch XV) Community Medicine.

Signature of the candidate

Place: Chennai

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ACKNOWLEDGEMENT

I gratefully acknowledge and sincerely thank Dr.R,SHANTHIMALAR M.D., D.A., Dean, Government Stanley medical college, Chennai for granting me permission to carry out the study.

I gratefully acknowledge and sincerely thank Dr.A.JAMILA., Vice Principal, Government Stanley medical college, Chennai for granting me permission to carry out the study.

I have no words to express my sincere gratitude to Dr. P .SEENIVASAN M.D., Professor and Head of the Department,

Department of Community Medicine, Government Stanley Medical College, Chennai, who has been a constant encouragement, perseverance and guidance, which has helped me by extending his knowledge and experience in the

successful completion of this study.

I extend my sincere gratitude toDr. J. ANAIAPPAN M.D.DCH., Dr. ARUN MURUGAN, M.D, DIH., PGHFWM., Dr. SARAVANA KUMAR M.D, DNB, MBA, PhD., Associate Professors, Department of Community Medicine, Government Stanley Medical College, Chennai, who helped me immensely by extending their knowledge and experience during the course of this study.

I extend my sincere gratitude to Dr. EVANGELINE MARY, M.D., Assistant Professor, Department of Community Medicine, Government Stanley MedicalCollege, Chennai for her guidance and full support in bringing out this study.

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Dr. YAMUNA DEVI M.D, Dr. SENTHIL ARASI M.D., Dr. KIRUTHIGA M.D., Assistant Professors, Department of Community Medicine, Government Stanley Medical College, Chennai, for their extended support and

encouragement during the course of this study.

I extent my sincere gratitude to Dr. VENNILA M.B.B.S., Block medical officer, Veerapandy Block PHC, for her invaluable support and encouragement.

I wish to thank all the faculty, Senior and Junior Postgraduates of Department of Community Medicine, Government Stanley Medical College, Chennai for their continuous encouragement and moral support during the study period.

I would also like to thank my parents, my beloved husband, in-laws, my brothers and my friends for their moral support throughout the study period.

Above all my heart full thanks to the participants who have been enthusiastically participated in the study.

Above all, I thank the Almighty for his grace and blessings which helped me to complete the task.

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ABBREVIATIONS

CVD DR FSSAI HbA1c HSC HUD IDF NCD NPCDCS NFHS NHM OHA PHC SDSCA SD SEA SPSS TN WHO

- - - - - - - - - - - - - - - - - - -

Cardio-vascular disease Diabetic Retinopathy

Food Safety and Standards Authority of India.

Haemoglobin A1C Health Sub-Centre Health Unit District

International Diabetes Federation Non-Communicable Disease

National Program for Prevention and Control of Cancer, Diabetes, Cardiovascular disease and Stroke

National Family Health Survey National Health Mission

Oral Hypoglycaemic Agents Primary Health Centre

Summary of Diabetes Self-Care Activities Measure Standard Deviation

South-East Asia

Statistical Package for Social Science Tamil Nadu

World Health Organization

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TABLE OF CONTENTS

S.NO

TOPICS PAGE

NUMBER

1. INTRODUCTION 1

2 OBJECTIVES OF STUDY 5

3 JUSTIFICATION 6

4 REVIEW OF LITERATURE 8

5 MATERIALS AND METHODS 32

6 RESULTS AND ANALYSIS 44

7 DISCUSSION 74

8 SUMMARY AND CONCLUSION 81

9 LIMITATIONS 85

10 RECOMMENDATIONS 86

11 REFERENCES 88

12 ANNEXURES 98

Annexure 1 Information Sheet (English,Tamil)

Annexure 2 Informed Consent Form (English, Tamil) Annexure 3 Questionnaire (English, Tamil)

Annexure 4 Modified B.G Prasad’s Classification Annexure 5 List of Blocks, PHC, HSC

Annexure 6 Urban Study Area Map Annexure 7 Key to Master Chart Annexure 8 Master Chart

Annexure 9 Plagiarism Certificate

Annexure 10 Ethics Committee Approval Certificate Annexure 11 List of Experts

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LIST OF FIGURES

FIGURE

NO TITLE

Page number

1. Management of type 2 diabetes 15

2 Selection of study participants through multi stage sampling in

rural area 35

3 Selection of study participants through multi stage sampling in

urban area 36

4 Age distribution in study participants 45

5 Sex distribution of study participants 46

6 Sex distribution of study participants 46

7 Educational status of study participants 46

8 Marital status of study participants 47

9 Distribution of type of families in Rural and Urban area 48

10 Socio-economic status of study participants 49

11 Duration of Diabetes mellitus among study participants 50 12 Family history of diabetes mellitus among study participants 51 13 Family history of diabetes mellitus among study participants 51

14 Treatment history among study participants 52

15 Utilisation of various treatment facilities by study participants 53 16 Utilisation of various treatment facilities by study participants

53

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18 Presence of co-morbidities among study participants

54 19 Prevalence of various self-care practices among rural and urban

study participants 56

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LIST OF TABLES

TABLE

NO TITLE

Page Number

1 Prevalence of hyperglycaemia in TN according to NFHS-4 11 2 Studies of Self-care in Diabetes in various parts of Tamil Nadu

and Pondicherry 26

3 Diagnosis of diabetes among study participants 51 4 Cross-tabulation between urban and rural participants and

various selfcare practices 57

5 Cross- tabulation between Educational status and dietary

practices among rural and urban study participants 59 6 Cross-tabulation between Socio-economic status and dietary

practices among rural and urban study participants 60 7 Cross tabulation between duration of Diabetes and practice of

dietary self-care among rural and urban study participants 61 8 Cross-tabulation between Educational status and Physical

activity among rural and urban study participants 62 9 Cross-tabulation between Educational status and Footcare

practices among rural and urban study participants 63 10 Cross- tabulation between Socioeconomic status and Foot care

among rural and urban study participants 64

11 Cross-tabulation between Educational status and Dental care

practice among rural and urban study participants 65 12 Cross-tabulation between Socioeconomic status and Dental care

among rural and urban study participants 66

13 Cross- tabulation between Socioeconomic status and practice of blood glucose monitoring among rural and urban study

participants

67

14 Cross- tabulation between Socioeconomic status and practice of screening for complications among rural and urban study

69

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15 Cross-tabulation between Marital status and Practice of Screening for complications among rural and urban study Participants

70

16 Role of health care personnel in self-care practices 73

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1. INTRODUCTION

In the era of evidence-based medicine, the World is witnessing the transition of mortality rates from communicable disease to non-communicable disease 1. Non- communicable diseases (NCDs), also known as chronic diseases, tend to be of long duration and they result from combination of genetic, physiological, environmental and behavioral factors 2.

Non-communicable diseases are collectively responsible for almost 70% of deaths worldwide. 82% of pre-mature death or death before age of 70 years occurring in low- and middle-income countries are due to non-communicable disease 3.

Coronary artery disease, Stroke, Cancers, Chronic respiratory diseases such as chronic obstructive pulmonary disease, asthma and Diabetes mellitus are the major non-communicable disease that are of public health importance. These 4 groups of disease account for 80% of all pre-mature death by non-communicable disease 2.

The rise of NCDs can be attributed mainly to change in lifestyle. Tobacco usage, physical inactivity, practice of unhealthy diet and harmful use of alcohol are identified as four major risk factors for NCDs.

NCDs being a Global Health challenge has also got its impact on the Nation’s economic growth and sustainable development. They also pose a major challenge towards achieving the 2030 agenda for Sustainable Development which states a target of reducing premature deaths from NCDs by one-third by 2030 2.

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NCDs also impede the progress made towards poverty alleviation. The poverty reduction initiatives in low-income countries are affected by NCDs by rising household costs associated with health care and also increasing the out of pocket expenditures.

Type 2 Diabetes mellitus, one of the non-communicable disease has been rising rapidly all over the world. In 1980, there were 108 million people with diabetes 4 and now this burden has been increased. Currently 425 million people across the world suffer from diabetes mellitus and this has been projected to increase to 629 million by the year 2045 if prompt actions are not taken 5.

The prevalence of Diabetes was high in urban population with the prevalence of 10.2% when compared to rural area which has got prevalence of 6.9% globally.

There is evidence from the previous studies that increasing prevalence of diabetes in rural areas is due to rapid urbanization and industrialization5.

Uncontrolled diabetes results in persistent hyperglycemia which in turn damages the blood vessel resulting in micro and macro vascular complications.

Diabetes is the leading cause for Coronary artery disease, Chronic kidney disease, stroke, lower limb amputations and blindness 5. Diabetes also exacerbates major infectious diseases such as TB, HIV/AIDS and malaria. This again results in increase in the health expenditure by the patients and also on the health care.

Diabetes - a silent killer, is also a global societal catastrophe due to its chronic nature causing devastating personal suffering, pushing families into poverty. In 2017, USD 727 billion of global healthcare expenditure is dedicated to Diabetes treatment

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and related complications. This has been an 8% increase when compared to the year 20155

In India,

Our nation ranks 2nd in the global burden of diabetes with 72.9 million people suffering from diabetes in 2017. If current trend continues, India may rank top among all countries by the year 20455.

India being a lower middle-income country faces double burden of disease.

While the nation fights against the threats posed by infectious diseases like HIV, Tuberculosis and Malaria it is also on the verge to tackle the rising tide of non- communicable disease.

In 2017, nearly 80 million people suffered from diabetes in India and among them half of the people i.e. 42.2 million remain undiagnosed which in turn derails the progress made towards reducing the burden 5. Often people become aware of their diabetic status only after the occurrence of complications related to diabetes. 6

Management of diabetes requires a multipronged and comprehensive approach. Both the treating physician and the patient must have an active participation for prompt management. Self-care being a secondary level of prevention has a major role in effective management of Diabetes.

Self-care activities are behaviors undertaken by people with or at risk of diabetes in order to successfully manage the disease on their own. Self-care practices include healthy eating, being physically active, regular monitoring of blood glucose,

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adherence to drugs as prescribed, problem solving skills, risk reduction behaviors and healthy coping up skills 7. All these practices have been found to be positively correlated with good glycemic control, delaying and reduction of complications and improvement in quality of life.8-11

Diabetes self-care requires the patient to make many lifestyle modifications in addition with the supportive role of healthcare staff for maintaining a higher level of self-confidence leading to a successful behavior change 12. Individuals with diabetes have been shown to make a good impact in delaying the progression and development of their disease by participating in their own care 13.

The importance of patients becoming active and knowledgeable participants in their own care has been emphasized by The American Association of Clinical Endocrinologists 14. WHO has also recognized the importance of patients learning to manage their diabetes 15 . The American Diabetes Association had documented that there was a four-fold increase in diabetic complications among individuals with diabetes who had not received formal education concerning self-care practices16 .Good adherence to self-care delays the development of complications, reduces hospital admission rate and thus improves outcome 17.

India being a developing nation, adopting self-care practices in management of diabetes will be a cost-effective approach in reducing the economic burden due to disease and thus fasten the progress towards achieving the sustainable developmental goal.

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2.OBJECTIVES

1. To assess and compare various self-care practices among patients with type 2 diabetes mellitus residing in rural and urban areas of Salem, Tamil Nadu.

2. To determine various factors influencing the self-care practices among patients with type 2 Diabetes mellitus.

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3. JUSTIFICATION

1. India being a second populous country, also ranks second next to China in the burden of Diabetes. This places our nation to face the risk of doubling the burden of Diabetes by the year 2045 5.

2. India being a Southeast Asian country, 12.2% of the total health care budget was spent on Diabetes in the year 2017 and in the same year our nation has spent 31 Billion International Dollars on the total healthcare expenditure for Diabetes5.

3. Self-care practices tend to be a promising cost-effective approach in the management of Diabetes7. Though our Government recommends self-care through counselling the patients under National Program for Prevention and Control of Cancer, Diabetes, Cardiovascular disease and Stroke (NPCDCS) 18 ,various studies showed poor adherence to self-care practices among Diabetic patients 19-23

4. Various factors like gender, illiteracy, socioeconomic status, poor access to drugs, lack of health literacy, poor access to health care, family support, unequal distribution of health care providers, preference to health care system tend to influence self-care practices and these factors differ in rural and urban areas. 24-26

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5. As there is dearth of evidence to compare the self-care practices in rural and urban areas, this study was undertaken to minimize the gap and to help in planning self-care education activities that suits people residing in different localities.

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4. REVIEW OF LITERATURE

Discoveries of Indians in various fields like mathematics, science, astronomy, and democracy has helped to shape the modern world. India has been in the forefront in contributing to the field of medicine. Knowledge of Indians in the field of medicine could be traced back to Vedic times when Charaka and Sushrutha were involved in treating sick people. Ancient Indians were also expertise in Diabetes.

Literature provides evidence that in 1500 B.C Indians noted the sweetness of urine and blood of patients with Diabetes. Aretaecus of Cappadocia in 133 A.D coined the term ‘Diabetes’. Later the word ‘mellitus’ (Latin, sweet like honey) was stated by British Surgeon General, Thomas wills in 1967 27.

4.1

Diabetes mellitus

Diabetes Mellitus, an endocrine disorder is characterized by derangement of glucose homeostasis which results in cardinal symptoms like polyuria, polyphagia and polydipsia. Though the cause for Diabetes was initially considered to be deficiency of insulin secretion from pancreas, modern day discoveries has led to establishment of facts that there are numerous other reasons like genetic and environmental factors that play a role in the development of Diabetes 28.

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4.1.1

Types of Diabetes Mellitus

2

Diabetes mellitus can be classified into four basic types depending on its etiology namely,

1. Type 1 Diabetes 2. Type 2 Diabetes

3. Other specific type of Diabetes which includes genetic defect.

4. Gestational Diabetes mellitus.

Type 2 Diabetes is the most common among all the 4 types 29. 4.2

BURDEN OF THE DISEASE

4.2.1 Global disease burden

According to International Diabetes Federation (IDF) , it was estimated in 2017 that 451 million people suffered from Diabetes Mellitus globally.5 Diabetes has also resulted in 5 million deaths worldwide among people belonging to age group of 20 to 99 years in the same year. This burden of Diabetes was expected to raise to 693 million by the year 2045.4

Currently 1 in 11 people suffer from Diabetes Worldwide. Among them, 2/3 of the people reside in urban area and remaining 1/3 reside in rural area accounting for 279 million people in urban areas and 146 million people in rural area. In the total burden of Diabetes, 67% of people belong to Working sector, which in turn has an impact on country’s economy.5

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4.2.2

Burden of Diabetes in South-East Asia (SEA)

IDF report stated that 84 million adults aged 18 to 99 suffered from Diabetes in South-East Asia in the year 2017.30 99 % of this burden is due to type 2 Diabetes mellitus and this was projected to increase to 156 million by the year 2045.5 Among them more than half of people were under diagnosed. The same report, stated that USD 9.7 billion has been spent on healthcare for the people with Diabetes.

In South-East Asia, the total annual costs for Diabetes care ranged from $ 483-$ 2637 per patient. Diabetes was responsible for catastrophic expenditure in 5.8% of the patients in 2017 31 in SEA countries.

4.2.2

Burden of Diabetes in India

India ranked front among all the SEA countries with 72,946,400 people living with Diabetes i.e. the prevalence was 8.8% in the year 2017.5

This huge burden imposed economic burden on individual, families, society and also on the governing body to take care of their middle age citizens (major working force) who were the most common age group affected by type 2 Diabetes.

The direct costs involve medical and non-medical costs in people with Diabetes which imposed burden on individuals and families and the indirect costs would be borne by the society and the government, related to loss of productivity.

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Bansode et al stated that the annual expenditure for Diabetes care by the patients in India was on average Rs.10,000 in urban area and Rs.6260 in rural area 32.

4.2.3

Burden of Diabetes in Tamil Nadu (TN)

A study conducted by India State Level Disease Burden Initiative Diabetes Collaborators showed that the prevalence of Diabetes in Tamil Nadu was more than 10.5% in 2016. The same study showed that there was more than 44%

change in percentage prevalence from the year 1990 to 2016.33

According to National Family Health Survey-4 (NFHS)34, the prevalence of hyperglycemia among adults aged 15 to 49 years in TN has been shown in the following table.

Table:1 Prevalence of hyperglycemia in TN according to NFHS-4.

Gender Blood sugar level mg/dl Rural Urban Total Men

High > 140 9.2% 10.2% 9.7%

Very high > 160 5.3% 5.9% 5.6%

Women

High > 140 6.3% 8.0% 7.1%

Very high > 160 3.4% 4.5% 3.9%

The above table clearly showed that, prevalence of hyperglycemia was more in urban area and the prevalence was higher in men aged 15 to 49 years.

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There was also increase in burden of Diabetes among rural population due to rapid urbanization, change in dietary habits and adopting sedentary lifestyle.

4.2.4

Burden due to Diabetes complications

35

.

Cardio-vascular disease (CVD) are the leading cause of death Worldwide and it is the major cause of death and disability among Diabetes patients. Largest proportion of inpatient costs in Diabetes were due to consequences of CVD.

Leading cause of vision loss among working force (people aged 20 to 65) was found to be Diabetes. IDF stated that 1 in 3 people with Diabetes have some form of Diabetic Retinopathy (DR) and 1 in 10 developed a vision threatening form of disease which adversely affects the Quality of life. It also stated that 76%

of DR can be prevented by good blood glucose control.

As a consequence of Diabetes, every 30 second a patient lost a lower limb or part of it which affects quality of life of people dramatically. Foot ulcer also increased the health expenditure by 5 times in Diabetic patients when compared with those without the disease.

Diabetes also increased the risk of periodontal disease. Various dental conditions like dental decay, candidiasis, lichen planus, neurosensory disorders (burning mouth syndrome), salivary dysfunction, xerostomia and taste impairment can also be seen in Diabetic patients.

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4.3

Risk factors for type 2 Diabetes Mellitus

28

The following were the risk factors for Type 2 Diabetes. Risk factors could be classified into modifiable and non-modifiable risk factors. Modifiable risk factors were those which can be changed by adopting healthy lifestyle while non- modifiable were those which could not be controlled.

Modifiable risk factors include,

• Obesity and overweight.

• Physical inactivity

• Hypertension (blood pressure ≥140/90 mmHg)

• Abnormal cholesterol level. High Density Lipoprotein level <35 mg/dl and/or a triglyceride level >250 mg/dl.

• History of cardiovascular disease.

• Previously identified with Impaired Fasting Glucose, Impaired Glucose Tolerance, or Hemoglobin A1c of 5.7–6.4%

• History of Polycystic ovary syndrome

Non-modifiable risk factors include,

• Age

• Family member suffering from Diabetes

• Race/ethnicity

• History of Gestational Diabetes Mellitus

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Screening of these high-risk individuals can help to identify the disease and its complications at an earlier stage. Employing lifestyle modification at the earliest could delay them from developing complications which in turn leads to improvement in quality of life.

4.4

Criteria for the diagnosis of Diabetes mellitus:

Diabetes could be diagnosed using anyone of the following criteria given by International Diabetes Federation 5.

• Random blood glucose concentration ≥ 200 mg/dl with symptoms of Diabetes

• Fasting plasma glucose ≥126 mg/dL or

• Hemoglobin A1c ≥ 6.5% or

• Oral glucose tolerance test showing 2-hour plasma glucose ≥ 200 mg/L 4.5

Management of diabetes

28

.

Management of Diabetes has been a comprehensive and multipronged approach which has to done lifelong. As there is increasing prevalence of obesity, physical inactivity and poor diet, diabetes once thought to affect older individual would not be applicable in today’s scenario.

Concept of Self-care in Diabetes has been evolved into a most promising approach in management of Diabetes. Diabetes could be managed effectively if one follows healthy lifestyle by adopting good dietary practices and engaging in regular physical activity. If desired blood glucose control has not been achieved,

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patient can be advised on Oral hypoglycemic agents along with lifestyle modification. Regular blood glucose monitoring and screening for complications could help patients to lead a good quality of life.

Figure:1 Management of type 2 Diabetes

28

.

4.6 Complications of Diabetes 28.

Uncontrolled Diabetes could end up in complications resulting in hospitalization and increasing the health expenditure. It results in lowering quality of life of people. Persistent hyperglycemia causes damage in vascular system thus affecting the vital organs of the body like heart, eyes, kidneys and nerves. Complications could be classified into microvascular, macrovascular depending on the blood vessel involved.

Type 2 Diabetes mellitus

Screen for/manage complications of Diabetes

Retinopathy Cardiovascular disease

Nephropathy Neuropathy Other complications Treat associated

conditions Dyslipidemia Hypertension

Obesity Coronary heart

disease Individualized

glycemic control Diet/lifestyle

Exercise Medication

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Microvascular complications include,

• Eye disease: Retinopathy & Macular edema

• Neuropathy: Sensory, Motor and Autonomic neuropathy

• Nephropathy (albuminuria and declining renal function)

Macrovascular complications include,

• Coronary heart disease

• Peripheral arterial disease

• Cerebrovascular disease

Other complications include,

• Gastrointestinal (gastroparesis, diarrhea)

• Genitourinary (uropathy/sexual dysfunction)

• Dermatologic manifestation

• Infections

• Cataracts

• Glaucoma

• Cheiroarthropathy a Periodontal disease

• Hearing loss

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Periodical screening for complications should be emphasized among patients with Diabetes to lead a good quality of life.

4.6.1

Awareness on complications of Diabetes:

A study conducted by Indian Council of Medical Research 36, among general population from 4 selected regions on India, showed that 51.5% of general public and 72.7% of diabetic patients were aware that diabetes could affect other organs.

A study conducted by Durgad et al 37, in Karnataka among Diabetic patients attending Tertiary care hospital, showed that 55% were unaware of complications of Diabetes.

Another study conducted in Mumbai among type 2 Diabetes mellitus patients to assess awareness on diabetes and its complications showed that almost 63% of study participants were unaware that diabetes affects retina 38.

4.7

Self-care in diabetes mellitus

Self-care in Diabetes has been defined as an evolutionary process of development of knowledge or awareness by learning to survive with the complex nature of the Diabetes in a social context.26

Self-care includes 7 domains namely healthy eating plan, increasing the physical activity, regular monitoring of blood glucose level, adherence to prescribed drugs, good problem-solving skills, practicing healthy coping up kills and adopting risk reduction behavior.26

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4.8

Recommended level of self-care practices

The following are the recommendations of various domains of self-care given under NPCDCS program by Ministry of Health and Family Welfare 18.

4.8.1

Diet

• Obese and overweight individuals must reduce their calorie intake by 500 to 600 calories / day.

• All patients are advised to add fruits and vegetables in diet (at least 400 gm/day).

• Sweets and foods with added sugar need to be avoided.

• Avoid foods with high glycemic index and to avoid deep fried items like bhajis, samosa, etc. Instead, food that are steamed and rich in fiber content like whole grains and green leafy vegetables can be chosen

• Daily consumption of salt should be restricted to <5gms /day/person.

• To split the food and eat as 3 meals and 2 snacks so that postprandial hyperglycemia can be avoided.

• Not to skip meals.

• Saturated fat consumption must be reduced.

4.8.2

Physical Activity

• Patients are advised to indulge in moderate physical activity like brisk walking, cycling and swimming for 150 mins/week.

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• This can be done by engaging in any of the above-mentioned activities for at least 30 mins/day, for 5 days in a week.

• Patients should not stay without physical activity for more than 2 consecutive days.

4.8.3

Foot care

• To wash feet using warm water and mild soap & to dry the foot with clean towel, especially between toes. Soaking of foot and using hot water for washing should be discouraged as it may precipitate ulcers.

• To inspect foot daily for cracks, blisters, ulcers should be done. A mirror can be used for this purpose.

• To prevent dryness of the foot, oil can be applied leaving areas between toes.

• To Clip toenails straight across using nail cutter.

• To choose slippers/shoes made of soft material and appropriate size.

• To avoid walking bare foot. Good to use slippers even inside the home.

• To seek doctor’s advice immediately, if there are any complaints in the foot

• To checking foot daily.

4.8.4

Adherence to drugs

• Patients are advised to take drugs/insulin as prescribed by the physician with self-modification of dose in all days in a week.

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• There should not be any sharing of drugs by the patients as drugs are prescribed according to the individual needs.

4.8.5

Smoking

Cessation of smoking must be encouraged.

4.8.6

Alcohol

Patients must be encouraged to give up the habit of alcohol consumption.

4.8.7

Screening for Complications

Patients with Diabetes must undergo

• Ocular examination to evaluate Diabetic retinopathy.

• Dental check-up.

• Renal function test.

• Lipid profile.

• Electrocardiogram at least once in a year to detect complications at the earliest

• Blood pressure monitoring must be done at least once in 3 months.

4.9

Diabetes education program for self-care

International Diabetes Federation (IDF) recommends all patients with Type 2 Diabetes has to undergo Diabetes education program at the time of diagnosis itself. This should be established from the Primary care level. It should

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be conducted by a trained program educator and in every primary health care level, one health care professional must be encouraged to become a diabetic educator.24

4.9.1

Advantages of self-care in Diabetes patients

17

Teaching diabetics about Self-care/self-management and following it successfully has shown advantages like:

1. Reduction in the hospital admission rate and lifetime health care cost. Thus, it is a cost-effective approach.

2. Improvement in HbA1c level by 1%.

3. Postponement of the onset and the advancement of complications.

4. Improvement in coping up skills in Diabetic patients.

5. Reduction in Diabetes related stress and depression.

6. Positive effect on clinical, psychosocial and behavioral aspects of Diabetes.

Thus, resulting in improving Quality of life.

4.10

Scales to assess self-care in diabetes:

Summary of Diabetes Self-Care Activities Measure 39.

This scale was developed by Toobert. It has 11 items that are used assess self-care activities practiced by patients in previous week. It addresses general diet, specific diet, exercise, blood glucose testing, foot care and smoking. this scale has been used in various studies as it showed appropriate psychometric qualities but its correlation with HbA1c level was less than DSMQ scale.

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Diabetes Self -Management Questionnaire (DSMQ) 40.

This scale developed by Schmitt et al has 16 items assigned in 4 subscales namely glucose management, dietary control, physical activity, health care use and sum scale. The internal consistency of this scale was good (0.84) and consistencies of the sub-scales were under acceptable level. The correlation of this scale with HbA1c level was significantly stronger than SDSCA scale. This scale can be applied to both type 1 and type 2 diabetic patients.

The LMC Skills, Confidence & Preparedness Index (SCPI)41.

SCPI is an electronic tool which has 25 items measures of three domains – knowledge, confidence and preparedness. The instant scoring and specific feedback and its relationship to glycemic control provides a valuable information to assess patients instantly. This scale had been evaluated using 120 study participants from tertiary care hospital and the results showed good intraclass correlation of 0.94 and internal consistency for the sub-scales was very good.

The Personal Diabetes Questionnaire (PDQ) 42.

It provides a brief and comprehensive measure of Diabetes self-care behaviors, perceptions and barriers which helps to guide the patients. The sub- scales used in this instrument demonstrated good internal consistency and demonstrated significant association with BMI and HbA1c level.

(36)

Diabetes Self-management Assessment Report Tool (D-SMART) 43.

It is an instrument which helps Diabetes educators to assess, facilitate, and track behavior change in the provision of Diabetes self-management education (DSME). This can be integrated in computer and telephonic system.

4.11

Knowledge on Self-care practices

A facility-based study done by Jackson et al44, in Kenya among type 2 diabetic patients to assess knowledge on self-care by Diabetics showed nearly 80% of participants had good knowledge. The results also showed statistical significance with level of education, monthly income and duration of diabetes.

Sari Alhaik et al 45, stated moderate (58.28%) knowledge on self-care practices among Diabetic patients recruited from 5 selected Primary Health Centers in Amman-Jordan. Participants had highest level of knowledge on meal planning and lowest knowledge on physical activity.

A facility based study conducted by Kassahun et al 46 among type 2 diabetics attending Jimma University Teaching Hospital, showed 34.9% of study participants had good knowledge on self-care to be adopted by diabetic patients.

A hospital based study conducted by Karam Padma et al in Karnataka among type 2 diabetics attending a tertiary care hospital in 2010, showed 61.68%

of participants were aware of importance of exercise, 75.21% were aware of dietary modification 47.

(37)

4.12

Studies on Self-care practices globally

A Study conducted in Western Ethiopia by Dadefo et al among diabetic patients attending DM clinic in Nekemte Referral Hospital during 2016, using SDSCA scale showed that satisfactory level of diet, exercise, foot care and Blood glucose monitoring was 69.4%, 63.5%, 82.9%, 15.1% respectively 48.

Another study in Ethiopia conducted among Type 2 diabetics attending health facility in 2013 showed that there was poor adherence to diet, self- monitoring of blood glucose and adherence to prescribed drugs by 75.9%, 83.5%, 4.3 % of study participants respectively 49.

Malaysian study among 126 diabetic adults in health care settings by Tan et al in 2008, showed that 80% of participants consumed more meals, 54 % were inactive, 46% were non-adherence to drug and only 15 % of study participants done self-monitoring of blood glucose 50.

4.13

Studies conducted in India on self-care practices among diabetic patients

A study conducted among diabetic patient residing in resettlement Colony in East Delhi by Mohandas et al from 2014 to 2016 51, showed that 31% practiced diet control on all seven days,16.7% of the people practiced physical activity,19

% of the patients done foot care and only 7.7 % of the respondents checked their blood glucose value in the past one week.

(38)

A facility based cross sectional study conducted in Mangalore by Rajasekaran et al among diabetics attending Government Wenlock Hospital in 2012, showed that healthy eating plan, daily exercise, regular monitoring of blood glucose level, adherence to medication was 45.9 %, 43.4 %, 76.6 %,60.5%

respectively 52 .

A community based cross-sectional study conducted in rural area Karnataka by Dinesh et al in 2014-2015 53, showed that dietary practice, exercising regularly, checking blood sugar once in three months, taking drugs every day and foot care was done by 24%, 20.5%, 62.25%, 48% and 0.5% of the study participants respectively.

Another community based cross-sectional study conducted in Anand district of Gujarat in 2010, showed results that dietary practice, physical activity, taking drugs regularly, self -monitoring of blood glucose level and level foot care was 70.42%, 24.33%, 88.1%, 16% and 42.3% for all 7 days in a week respectively

54.

Following table shows Self-care practices followed by patients with type 2 Diabetes in various parts of Tamil Nadu and Pondicherry.

(39)

Table:2 Studies on Self-care in Diabetics in various parts of Tamil Nadu and Pondicherry.

Researcher Area of

study Year

Type-of study

DP (%)

PA (%)

BGM (%)

FC (%)

ADH (%) Kalaiselvi

Selvaraj 19 Pondicherry 2013 Facility

based 32.8 33.3 78.8 8.6 95.6 Shrivastava 20 Kancheepur

am 2014 Camp

based 78 29.3 76.2 17.2 72 Uma

Maheshwari 21

Tiruvallur 2016 Facility

based 76.9 57.1 84.1 36.7* 89.7 Veerakumar

22 Trichy 2016

-17

Facility based

80*

* 65 94 48 -

Gopichandran

23 Vellore 2009

Commu nity based

29 19.5 70 - 79.8

*- Drying skin between toes on all days in a week, **- Avoided sugar on all days in a week

[DP-Dietary practice, PA- Physical activity, BGM- Blood glucose monitoring at least once in 3 months, FC-foot care, ADH-adherence to drug]

It was clearly seen from the above studies that dietary practices were adequate in more than half of them. Practices like foot care, monitoring blood glucose was comparatively poor in the study participants in all the above-mentioned studies.

(40)

4.14

Barriers to self-care practices

A multinational study conducted by Adu et al to identify enablers and barriers to effective self-management among diabetes, identified frustration due to dynamic and chronic nature of Diabetes, financial constraints, unrealistic expectations and work and environment-related factors as barriers to adhere to self-care.24

Lack of knowledge, loss of wages, lack of family support, cultural constraints, lack of trust in public health care system, doctor patient communication gap are identified as barriers to adopt self-care among Diabetes patients by Chetan et al in Karnataka.25

Shrivastava et al has stated attitude, beliefs, knowledge about Diabetes, culture and language capabilities, health literacy, financial resources, co- morbidities and social support as patient factors responsible for poor self-care among Diabetic patients.26

4.15

India’s initiative to tackle raising burden of Diabetes:

4.15.1 National program for the Prevention and control of Cancer, Diabetes, Cardiovascular Disease and Stroke.18

Government of India came up with a program to control raising burden of Non-communicable disease in 2010. The program was named as National program for the Prevention and control of Cancer, Diabetes, Cardiovascular Disease and Stroke. Later in 2013 it was integrated with National Health Mission.

(41)

The main Non-communicable disease focused in this program include,

❖ Diabetes Mellitus,

❖ Hypertension,

❖ Breast Cancer,

❖ Cervical Cancer and

❖ Oral Cancer.

Objectives of NPCDCS

❖ Community participation for Health promotion

❖ Population based screening and Opportunistic screening at all levels of Health care.

❖ To prevent and control common NCD’s.

❖ Cost-effective treatment and diagnosis for NCD’s.

❖ Strengthening surveillance for development of database.

Principles of management of Type 2 Diabetes as per NPCDCS

❖ Lifestyle modification which includes dietary modification and physical activity.

❖ Reducing insulin resistance through weight reduction.

❖ Pharmacological treatment with Metformin and sulfonylureas.

❖ Treating high blood pressure with ACE inhibitors, calcium channel blockers and diuretics.

❖ Using statins for lipid control.

(42)

NPCDCS also provides guidelines for counselling patients with Diabetes.

At PHC level – staff nurse or multipurpose health worker should be trained to provide counselling and health education.

At sub-district and district level hospital - Dietician or Counsellor or staff nurse to be appointed to provide Diabetes education.

The following topics were addressed during health education session during initial and follow up visits as recommended under NPCDCS.

In initial visit:

❖ Information about diabetes

❖ Cause for diabetes mellitus

❖ Lifestyle modification

❖ Use of Oral Drugs and good adherence

❖ Advice on identifying signs and symptoms of hypoglycemia and hyperglycemia and their Management.

❖ Information about the importance of factors other than glucose control like control of Cholesterol, blood pressure, stopping smoking/tobacco, etc.

During follow-up visit

❖ Importance of Glycemic Control

❖ Prevention of Complications

❖ Foot Care

(43)

❖ Newer modalities of treatment

❖ Marriage Counseling Pre-conceptional counselling regarding the importance of glucose control prior to Pregnancy.

4.15.2

mDiabetes

55

WHO and The Ministry of Health and Family Welfare, India worked together and launched a mobile health initiative for the prevention and care of Diabetes. As India has got over a million mobile subscriptions, this opportunity has been utilized by the government to deliver health care.

People can register in mDiabetes using their phone number or email id or give a missed call to 011-22901701. On registering the participants, will receive a text message about diabetes, dietary modifications, physical activity etc. mDiabetes also provides information on Diabetes risk assessment. On providing information like age, sex, height, weight, family history of diabetes, waist circumference diabetes risk score is calculated and followed by advice for screening.

mDiabetes also contributes to

❖ improving awareness about diabetes

❖ promoting healthy diet and active lifestyle

❖ enhancing health care seeking behavior and early diagnosis

❖ contribute to better drug adherence, self-care and prevention of complications.

(44)

31

4.15.3

Eat Right India

56

To combat negative nutritional trends prevailing in our country, which contributes to lifestyle disease, FSSAI has launched the ‘Eat Right India Movement’. This initiative mainly focusses on nutrition and encourages people to make choices on nutritious food including green leafy vegetables and fruits.

Eat healthy campaign is covered under this movement to promote healthy dietary practices among Indians. It also provides dietary modifications necessary for Diabetics

(45)

5.MATERIALS AND METHODS

5.1 Study design

Community based Cross-Sectional Study.

5.2

Study area:

This study was conducted among selected villages in rural areas and selected wards in urban areas of Salem district, Tamil Nadu.

5.3

Study period

The study was carried out from January 2018 - February 2019 (13 months).

5.4

Study population

This study was conducted among patients with Type 2 Diabetes Mellitus residing in selected rural and urban areas in Salem, Tamil Nadu

5.4.1

Inclusion criteria

1.Both men and women aged 30 years and above who have physician diagnosed type 2 Diabetes mellitus for at least 1 year and residing in the selected locality for at least 1 year.

2.Those who gave consent to participate in the study.

(46)

5.4.2

Exclusion criteria

1. Patients with Type 2 Diabetes with acute febrile illness.

2. Patients with Type 2 Diabetes diagnosed with End stage renal disease, Cardiovascular and Cerebrovascular disease within 1 month from the date of interview.

3. Patients with Type 2 Diabetes who are bed-ridden and mentally challenged are excluded from the study.

5.5

Sample size

The Sample size was calculated based on the study,” Self-Care Activities among patients with diabetes attending a Tertiary care hospital in Mangalore Karnataka, India” by D. Rajasekaran et al 52. In that study 13.4% of participants examined the inner surface of their footwear for blood or other discharges (one of the self-care practices) on all days of the week. Considering Confidence level of 95 %, absolute precision of 5 % and 10 % to account for non-response, the sample size was derived as follows,

Sample size was calculated using the formula:

N = Z 1-a2 pq/d2

Where, - Z 1-a2 =standard normal deviant at 95% confidence level i.e. 1.96 p = prevalence = 13.4,

q = 100 – p = 86.6,

(47)

d = absolute precision of 5 %,

N = 1.96*1.96*13.4*86.6/5*5= 178.3.

Allowing a 10 % non-response rate the sample size was 196 and on rounding of the sample size is 200.

Being a comparative cross-sectional study, 200 participants were selected from rural area and another 200 participants were selected from urban area.

5.6

Sampling method

The study participants were selected by Multi-stage random sampling.

5.6.1

For Rural area:

❖ Salem Health Unit District (HUD) consists of 20 Blocks. (Annexure-5)

❖ Veerapandy block was chosen by simple random sampling using lots method.

❖ In Veerapandy block there are 5 Primary Health Centers (PHC) and among them Murungapatty Primary Health center was chosen by simple random sampling using lots method.

❖ Murungapatty Primary Health center has 4 Health Sub-Centers (Murungapatty, Ariyagoundampatty, Perumampatty, Maramangalathupatty) under it.

❖ Among them Murungapatty Health sub-center was chosen by simple random sampling using lots method. Murungapatty HSC has 1487

(48)

households and serves a population of 7,395.

❖ The details of households were obtained from Village Health Nurse. With the sample size of 200, and a sampling interval of 7, a random number of 5 was chosen and study was started with 5th household from the HSC and there after every 7th house was chosen till sample size of 200 was obtained.

❖ If selected household had no participants satisfying inclusion criteria, the next household was included in the study.As the required sample size was not reached, repeated systematic sampling was done till the required sample size was attained.

Figure:2 Selection of study participants through Multistage sampling in Rural area.

1st

Veerapandy Block - 5 PHCs 2nd

Murungapatti PHC - 4 HSCs 3rd

4th

Murungapatti HSC - 1487 households

5th

Residents of selected house- hold satisfying inclusion criteria

Salem HUD - 20 Block PHCs

Repeated Systematic Random Sampling Simple Random

Sampling Simple Random

Sampling Simple Random

Sampling

(49)

5.6.2 For Urban area:

❖ Salem corporation consists of 60 wards. (Annexure-6)

❖ Ward 33 was chosen by simple random sampling using lots method.

❖ The details of households were obtained from Urban Health Nurse. Ward 33 has 4037 households. As the sample size was 200 and sampling interval was 20, a random number of 5 was chosen and study was started with 5th household from the Urban PHC and there after every 20th house was chosen till sample size of 200 was obtained.

❖ If selected household had no participants satisfying inclusion criteria, the next household was included in the study.As the required sample size was not reached, repeated systematic sampling was done till the required sample size was attained.

Figure:3 Selection of study participants through Multistage sampling in Urban area.

1st

2nd

3rd

• Salem Corporation - 60 Wards

Simple Random Sampling

• Ward Number 33 - 4037 households

Repeated Systematic Random Sampling

• Residents of selected house- hold satisfying inclusion

(50)

5.6.3 Selection of sampling unit:

In the selected houses, residents were verified if they were present in the same locality for 1 year and were enquired about the health status of the family members. If any member satisfied the inclusion criteria and gave consent, they were enrolled in the study.

If selected house was a multi-storied building, the households to be selected for the study was chosen randomly. When selected house had more than one eligible person satisfying inclusion criteria, the study participant was chosen randomly among them using lots method. If the selected house was locked even after 2 visits, that household was excluded, and the adjacent household was selected as the sample.

5.7

Data collection tool:

The information regarding self-care activities among patients with type 2 diabetes was collected using the revised version of Summary Diabetes Self-Care Activities questionnaire (SDSCA). The Questionnaire was prepared according to local culture in English and translated into the local language Tamil and back translated again to ensure appropriateness of translation.

Questionnaire was pilot tested among 30 individuals in local language and necessary corrections were made. Finally, a semi structured pretested questionnaire in regional language (Tamil) was used for data collection which has the following sections.

(51)

Section 1: Socio demographic profile & addictive habits.

Section 2: Details on Diabetes Mellitus which includes questions on duration of diabetes, diagnosis, family history, type of treatment facility, medications and co- morbidities.

Section 3: Details on awareness of self-care practices which includes questions on diet, physical activity, foot care, adherence to drug, blood glucose monitoring, screening for complications and hypoglycemia management.

Section 4: Self-care practices focusing on domains such as diet, physical activity, foot care, adherence to drug, blood glucose monitoring and screening for complications.

Section 5: Role of Health-care personnel.

The questionnaire is given in the Annexure-3 in this book.

5.8

Data collection method:

Data collection was done in the study area after obtaining official permission from the Dean, Government Stanley medical College, Chennai, Deputy Director of Health Services, Salem and City Health Officer, Salem.

Details of the study was informed to the Medical officer of Veerapandy block, the Medical officer of Murungapatty PHC and the Medical officer of Urban PHC, Ammapettai (Ward 33).

(52)

Approval for the study was obtained from the Institutional ethics committee, Stanley Medical College (Annexure-10). The information regarding the study was explained in local language to the study subjects (Annexure-1).

After their understanding and willingness to participate in the study, written informed consent was obtained (Annexure-2). Then study participant was interviewed using the questionnaire by face to face interview method.

Questions were read out to the study subjects in exactly the same order as listed in the questionnaire and sufficient time was given to the subject to respond.

If the respondent did not understand the questions, it was repeated in the same manner without probing for the answer. If the respondent was still doubtful about the answer, it was recorded as No.

5.9

Service rendered

Persons found to have complications of diabetes like foot ulcer, visual problem, reduced urinary output, frequent infections were referred to the nearest public health facilities for further management. Persons with poor self-care were educated about various self-care practices and its advantages and encouraged to follow it regularly.

5.10

Statistical analysis

After data collection, the details were entered in Micro Soft Excel and analyzed using SPSS software version 16. For categorical data, frequencies and proportion were calculated. For continuous data, mean and standard deviation or

(53)

median and inter-quartile range were calculated. Chi- square test was used as test of significance for categorical data. A p value of less than 0.05 has been considered to be statistically significant.

5.11

Variables of interest and operational definition

5.11.1 Physician diagnosed Type 2 Diabetes Mellitus:

Any person aged 30 years and above found to be positive for any one of the following tests by the physician.

1. Fasting glucose = ≥126 mg/dL (7.0 mmol/L)

2. 2-hour blood glucose estimation following ingestion of 75-g glucose load =

≥200 mg/dL (11.1mmol/L)

3. Random plasma glucose in symptomatic patient = ≥200 mg/dL (11.1 mmol/L) 4. HbA1c = ≥6.5% (48 mmol/mol)

• (Fasting is defined as no caloric intake for at least 8 hours.

• The HbA1c test should be performed in a laboratory using a method that is NGSP-certified and standardized to the Diabetes Control and Complications Trial assay.

• The 2-hour postprandial glucose test should be performed using a glucose load containing the equivalent of 75-g anhydrous glucose dissolved in water.)

(54)

5.11.2

Self-care practices in Diabetes Mellitus:

Self-care practices are behaviors undertaken by people with diabetes in order to successfully manage the disease of their own.

In this study, healthy eating plan, increasing the physical activity, foot care, dental care, regular monitoring of blood glucose level, adherence to prescribed drugs, screening for complications and life free from having addictive habits are the 8 domains considered under self-care.

A.

Diet:

In this domain 5 questions were framed, and all questions were given score from 0 (none of the days in a week) to 7 (all 7 days in a week) based on the practice of study participants. A cumulative score was obtained and converted into percentage. The questions under dietary domain were,

1.Reduced the serving size of Cereal based food like idly, dosa, cooked rice 2.Consumed Vegetables

3.Avoided high fat containing foods (fried items, red meat) 4.Avoided sugar rich foods

5. Followed splitting of meals.

In the dietary domain, self-care was considered good if the patient had followed the self-care measures for more than 75% of the time in a week.

(55)

B.

Physical activity:

Following moderate physical activity like brisk walking, swimming etc.

for at least 30 mins per day for 5 days in a week is considered as good self-care under the domain of physical activity.

C.

Foot care:

Under foot care, 6 questions were framed and all questions were given score from 0 (no days in a week) to 7 (all 7 days in a week). A cumulative score was obtained and converted into percentage. Questions were

• Examined foot for cracks, blisters, wounds

• Washed foot with soap and water

• Dried the skin between the toes

• Applied oil to the feet

• Examined the footwear for discharge

• Used footwear inside the house.

In this domain, good self-care was ascertained if the patient had followed the self-care measures for more than 75% of the time in a week.

D.

Dental care:

Brushing teeth twice daily for is considered as a good self-care.

E.

Adherence to drug:

Taking oral hypoglycemic agents or insulin in a dosage as prescribed by the treating physician for at least 6 days a week was taken as a good self-care.

(56)

F.

Blood glucose monitoring:

Monitoring venous blood glucose concentration at least once in 3 months was considered as good practice.

G.

Screening for complications:

❖ Checked Blood pressure at least once in 3 months.

All the following examinations to be done at least once in a year.

❖ Fundus examination done at least once in a year.

❖ Dental check-up.

❖ Renal function test.

❖ Electrocardiogram

❖ Lipid profile

Screening for complications using these tests was verified using the records present with the participants.

(57)

6. RESULTS AND ANALYSIS

This study included 200 participants in rural area and 200 participants from urban area, obtained from 923 households from rural area and 804 households from urban area. Data collected were entered in Microsoft excel and analyzed using SPSS software version 17.

Simple frequencies were used to analyze socio demographic characteristics like gender, education, socioeconomic status, addictive habits and diabetic profile of participants like medications, type of treatment facility and co-morbidities.

Awareness on self-care practices was analyzed using simple frequencies.

Independent sample T test was done to compare the cumulative awareness scores between urban and rural study participants.

Chi-square test and Fisher’s exact test were used for analysis to check for association between various demographic characteristics and self-care practices.

p value < 0.05 is considered as statistically significant.

Simple frequencies were used to analyze the barriers and role of health care personnel.

(58)

6.1

Socio demographic characteristics of study participants:

6.1.1 Age distribution of study participants:

Figure:4 Age distribution of study participants (N = 400)

The mean age of study participants was 51.4 years with standard deviation of 11.2 years. The mean age of study participants in rural area was 51.49 years (S.D = 11.5) and in urban area it was 51.35 years (S.D = 11). In rural area, most of the study participants belonged to more than 60 years of age group (29%) followed by 41 to 50 years age group (28.5%). In urban area, most of the study participants belonged to 51-60 years age group (30.5%) followed by 41-50 years age group (27%).

41-50 51-60 >60

Age in years

Rural Urban 31-40

40 30 20 10 0

47(23.5%) 40(20%)

38(19%)

58(29%)

45(22.5%)

50

57(28.5%)

60 54(27%) 61(30.5%)

70

Age distribution of study participants (N=400)

Frequency

(59)

6.1.2

Sex distribution of study participants:

Figure:5 and 6 Sex distribution of study participants

Both in rural and urban area, females were the major study participants.

6.1.3

Educational status of study participants:

Figure:7 Educational status of study participants (N=400)

In rural area, most of the study participants had completed secondary level of education (43%) followed by diploma and higher level of education (28.5%) but

Female Male

59.5%

Urban (N=200)

40.5%

Femlae Male

56%

Rural (N=200) 44%

100

Educational status of study participants (N=400)

86(43%) 91(45.5%)

80 60(30%) 57(28.5%

60 36(18%) 41(20.5%)

40 21(10.5%)

20 8(4%)

0

Illiterate Secondary level Higher secondary level Diploma and above

Educational status Rural Urban

Frequency

(60)

in urban area, most of the study participants had completed diploma (45.5%) followed by secondary level of education (30%).

6.1.4

Marital status of study participants:

Figure:8 Marital status of study participants (N=400).

Nearly ¾ th of study participants were married in both rural and urban area i.e. 144 (72%) and 140 (70%) respectively.

Marital status of study

participants (N=400)

300

140(70%)

200

150

17(8.5%)

50 10(5%)

0 14(7%)

Married Unmarried

5(2.5%)

Divorced

37(18.5

Widow/widowe Marital r

status Rural Urban

%) 33(16.5%) 144(72%)

Frequency

References

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